Ovid: Stewart: Can Med Assoc J, Volume 152(9).May 1, 1995.

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1995 Canadian Medical Association; Association mdicale canadienne

Volume 152(9) 1 May 1995 pp 1423-1433

Effective Physician-Patient Communication and Health Outcomes: A

Review
[Current Review]

Stewart, Moira A.

Dr. Stewart is with the Thames Valley Family Practice Research Unit, Centre for Studies in Family Medicine,
University of Western Ontario, London, Ont.
Reprint requests to: Dr. Moira A. Stewart, Centre for Studies in Family Medicine, Kresge Building, University of
Western Ontario, London ON N6A 5C1.

Outline

z Abstract
z DATA SOURCES
z SELECTION OF STUDIES
z CLASSIFICATION OF COMMUNICATION
z ANALYSIS
z FINDINGS
z Studies of history-taking
z Randomized controlled trials
z Analytic studies
z Summary
z Studies of the discussion of the management plan
z Randomized controlled trials
z Analytic studies
z Summary
z Studies of other aspects of communication and patient health outcome
z DISCUSSION
z Sharing power
z EDUCATION
z FUTURE RESEARCH
z REFERENCES

Graphics

z Table 1
z Table 2
z Table 3
z Table 4
z Table 5
z Table 6
z Table 7

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Abstract
Objective: To ascertain whether the quality of physician-patient communication makes a
significant difference to patient health outcomes.

Data sources:
The MEDLINE database was searched for articles published from 1983 to
1993 using "physician-patient relations" as the primary medical subject heading. Several
bibliographies and conference proceedings were also reviewed.

Study selection: Randomized controlled trials (RCTs) and analytic studies of physician-
patient communication in which patient health was an outcome variable.

Data extraction: The following information was recorded about each study: sample size,
patient characteristics, clinical setting, elements of communication assessed, patient
outcomes measured, and direction and significance of any association found between aspects
of communication and patient outcomes.

Data synthesis: Of the 21 studies that met the final criteria for review, 16 reported positive
results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality
of communication both in the history-taking segment of the visit and during discussion of the
management plan was found to influence patient health outcomes. The outcomes affected
were, in descending order of frequency, emotional health, symptom resolution, function,
physiologic measures (i.e., blood pressure and blood sugar level) and pain control.

Conclusions: Most of the studies reviewed demonstrated a correlation between effective

physician-patient communication and improved patient health outcomes. The components of
effective communication identified by these studies can be used as the basis both for
curriculum development in medical education and for patient education programs. Future
research should focus on evaluating such educational programs.

According to a recent consensus statement on physician-patient communication, [1]

"effective communication between doctor and patient is a central clinical function that cannot
be delegated." On what basis should such a pronouncement be made? Where is the evidence
that communicating well with patients makes any difference to outcome? The purpose of this
systematic review of 25 years of research is to evaluate the effects of various styles of
communication on patient health and to identify the characteristics of excellent
communication. The studies reviewed were conducted in a variety of clinical settings, and
their findings are of relevance to physicians in all areas of practice.

For years it was commonly thought that physician- patient communication was generally
adequate and was not a cause for concern. More recently, however, evidence has mounted to
the contrary. Numerous complaints stemming from breakdowns in physician-patient
communication have been made to licensing bodies, [2] and headlines declaring an "urgent
need for MDs to relate better to patients" and criticizing the "cold, hard" manner of
physicians have appeared in the medical and popular press [3-5]. Before we dismiss such
claims as sensational, we must review the evidence of well-conducted studies on the nature
and magnitude of physician-patient communication problems.

Some of these problems can arise during history- taking or during discussion of how the
patient's problem should be managed. Some may be related to a lack of communication skills
on the part of either the physician or the patient. In general terms, communication difficulties

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can be described with reference to problems of diagnosis, a lack of patient involvement in

the discussion or the inadequate provision of information to the patient. Studies have shown
that 50% of psychosocial and psychiatric problems are missed, [6] that physicians interrupt
patients an average of 18 seconds into the patient's description of the presenting problem, [7]
that 54% of patient problems and 45% of patient concerns are neither elicited by the
physician nor disclosed by the patient, [8] that patients and physicians do not agree on the
main presenting problem in 50% of visits [9] and that patients are dissatisfied with the
information provided to them by physicians [10]. These studies point to the conclusion that
problems in physician-patient communication are common and worthy of our attention.

For the most part, the studies reviewed here described communication problems with
reference to the flow of information from patient to physician during history-taking and from
physician to patient during discussion of the management plan. However, most of the studies
also point to the importance of emotional support as a dimension of communication. In
addition, the distribution of power and control in the physician-patient relationship --
particulary with reference to decision making -- is an implicit or explicit concern in all of the
studies reviewed.

Two constructive responses to the common -- and complex -- problems that arise in
physician-patient communication are, first, to identify the main characteristics of these
problems and, second, to mount educational programs aimed at solving them. Both of these
responses are based on the premise that communication skills can be taught [11].

Previous reviews have yielded annotated bibliographies, [12,13] focused on the relation
between communication and patient satisfaction, [14] dealt with research issues, [15] linked
communication with quality of care, [16] described a framework for teaching and learning
communication skills [17] and reviewed patient compliance [18]. Although these studies
implicitly or explicitly endorsed good physician-patient communication, none reviewed work
linking communication with patient health outcomes.

DATA SOURCES
A MEDLINE search was conducted of studies published from 1983 to 1993, and a review
of six bibliographies was carried out [12-17]. The MEDLINE search retrieved all articles
indexed with the medical subject heading (MeSH) "physician-patient relations" and at least
one of the following as a major aspect of the article: "communication," "medical history
taking," "interviews," "recall," "consumer satisfaction," "patient satisfaction," "patient
compliance," "referral and consultation," "outcome assessment (health care)," and "outcome
and process assessment (health care)." The search excluded articles indexed with the MeSH
term "psychotherapy" and its more specific associated terms as major aspects of the article.
Retrieval was limited to articles in English and excluded letters, editorials and news items.
After titles and abstracts were scanned, papers were classified into six types: review articles,
conceptual articles, descriptive studies of communication, observational studies without
patient outcome measures, observational studies with patient outcome measures, and
controlled intervention studies with patient outcome measures. This review of findings
focuses on the observational and intervention studies that included patient health as an
outcome variable.

SELECTION OF STUDIES
Studies were selected only if they met the following criteria.

- Design: Two design types were acceptable: those in which physicians or patients
randomly received different interventions to improve communication approaches (using

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patient health outcomes as the standard for evaluating the interventions); and those in
which communication behaviours were observed but not altered and in which naturally
occurring variations in communication were evaluated in relation to patient health outcomes.

- Subjects: The subjects of the studies included in the review were patients (of all ages) and
physicians (including residents) in community or teaching hospitals, walk-in clinics and
private practices. No medical specialty was excluded.

- Communication measures and interventions: Each study's description of the aspects of

communication examined had to be sufficiently complete to make replication of interventions
and measurements possible. Communication could be measured directly, through evaluation
of an audio- or videotape recording, or indirectly, through evaluation of the reported
perceptions of the patient or physician or both. Interventions could be conducted with either
the physician or the patient.

- Outcomes: Dependent variables were restricted to patient health outcomes as measured

by physiologic status, functional status, symptom resolution and emotional status.

- Data analysis: Results were recorded as percentage differences between groups, mean
differences between groups or statistical significance of findings.

CLASSIFICATION OF COMMUNICATION
Communication was classified as relevant either to history-taking or to discussion of the
management plan. When communication was described in a way that could not be classified
as relating to either of these it was categorized as "other."

ANALYSIS
Given the wide variety of communication approaches and health outcome measures used
in the studies, a formal, quantitative meta-analysis was impossible. This review, therefore,
presents tabulated summaries in which the level of statistical significance reported by the
investigators is indicated. Results in the expected direction that achieved conventional
statistical significance (p < 0.05) were considered "positive"; findings of nonsignificant
differences in studies with sufficient power were considered "negative"; and findings of
nonsignificant trends in studies with insufficient power to detect important differences were
considered "inconclusive."

FINDINGS
The database and bibliographic search retrieved 143 relevant articles. These consisted of
41 conceptual articles, 14 review articles, 16 descriptive studies, 5 qualitative studies, 14
analytic studies of communication in relation to factors other than patient outcomes, 42
analytic studies reporting patient outcomes (10 reported health outcomes and 32 other
outcomes such as patient satisfaction) and 11 randomized controlled intervention studies with
health outcomes. The 10 analytic studies and the 11 randomized controlled trials (RCTs) met
the final selection criteria.

Studies of history-taking
Randomized controlled trials

Four of the studies [19-22] were RCTs examining elements of communication during
history-taking Table 1; these provide level I evidence [23]. Interventions with relevance to

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history-taking were implemented with one or more randomly chosen groups; a control
group received no intervention. The subjects were adults attending family practices or
outpatient clinics. In two of these studies physicians were given training in communication
skills; in the other two, patient education was provided. The association of these interventions
with a variety of outcomes, including emotional status, role function and physiologic
measures, were both statistically and clinically significant. These studies had a high degree of
internal validity in view of their use of random allocation, the comparability between groups
and the use of single or double blinding. However, their external validity or generalizability
was not demonstrated.

Table 1. Randomized controlled trials of physicians-patient communication during history-taking

Analytic studies
The results of the analytic studies of communication during history-taking are summarized
in Table 2. These were essentially cohort studies and therefore provide level II-2 evidence [23].
Communication was assessed either in light of the reported perceptions of the patient or by
analysis of an audiotape of the patient's visit. Subsequently, health outcome was assessed
through the patient's own report, the physician's report or a test administered by a third party.
Health status measures focused on physical indicators and included symptom resolution
[24,25,26] and blood pressure [27]. Two of the studies used univariate analyses and found
statistically and clinically significant associations between increased communication (i.e., the
physicians asking more questions [25] and the patients making more statements [27]) and

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symptom resolution. Multivariate analyses that controlled for other important clinical
variables were used in the remaining two studies. One of these, [24] involving patients
presenting with a new episode of headache, found a highly significant association between
patients' perceptions of how fully their headache had been discussed and the resolution of the
headache after 1 year, adjusting for 15 other variables related to headache resolution such as
duration, frequency, accompanying symptoms, organic diagnosis, other risk factors and
psychosocial factors. The remaining study [26] found that the correlation of the frequency of
patient statements with symptom status dropped to a nonsignificant level when baseline
symptom status was controlled for.

Table 2. Analytic studies of physician-patient communication during history-taking

Summary
In the studies that focused on history-taking, both physician and patient education were
found to improve patient health outcomes. Physician education was demonstrated to affect
the patient's emotional status, whereas patient education was demonstrated to affect physical
health, level of function, blood pressure and blood glucose level. Of these eight studies, seven
obtained significant positive findings and one a negative (nonsignificant) result. Those
aspects of history-taking that were found to have a significant association with patient
outcomes are summarized in Table 3.

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Table 3. Elements of effective history-taking

Studies of the discussion of the management plan

Randomized controlled trials

Seven RCTs of elements of communication in the discussion of the management plan

(level I evidence) met the final selection criteria. Three of these [20-22] dealt with history-
taking as well and are summarized in Table 1. The remaining four [28-31] are summarized in
Table 4. In these seven studies an intervention relevant to the discussion of management was
given to one or two groups of randomly chosen subjects; a control group received no
intervention. The subjects were adults attending hospitals, outpatient clinics or family
physicians' offices for a wide variety of reasons. Six of the interventions involved patients.
Four of these [21,22,28,29] were designed to help patients to improve their information-seeking
skills; the other two [30,31] were intended to provide the patients with information about
treatment or the recovery period. In the remaining study [20] physicians were given training in
handling emotions and exchanging information.

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Table 4. Randomized controlled trials of physician-patient communication during discussion of the management plan

The outcomes that were found to be influenced by these interventions were emotional
status, pain, functional status, blood pressure and blood sugar level. These studies were well
designed and well executed; in three instances, the objective measure of outcome was
blinded.

Analytic studies
The design and results of analytic studies of communication regarding the management
plan that met the review criteria are summarized in Table 5. Two of these [32,33] were
nonrandomized evaluations of interventions (level II-1 evidence [23]). The others [9,34,35]
were cohort designs (level II-2 evidence). Three of the cohort studies summarized in Table
2assessed variables relevant to communication regarding the management plan and also
warrant discussion here [25-27]. In the eight analytic studies a wide range of communication
variables were considered: frequency of informative statements by the physician; [25-27]
whether the patient saw a presentation about radiation therapy; [32] whether the patient was
given a choice of surgical intervention; [33] whether the patient's surgeon permitted a choice
of treatment; [34] and whether the physician and patient agreed as to the nature of the
presenting problem [9,35]. Outcome was measured with respect to the patient's emotional
health, symptom resolution, physical problems and blood pressure. Six of the eight analytic
studies found statistically and clinically significant associations between the aspect of

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communication examined and patient outcome. However, none of these used multivariate
techniques to control for baseline health or other potentially confounding factors. One of the
two studies whose results were not statistically significant used an analysis that controlled for
baseline symptom status; [26] the fact that the remainder of the studies did not do so may be
an important limitation. The other study that obtained nonsignificant results [33] involved a
very small sample (20 patients who were given a choice of surgery and 10 who were not).
The magnitude of the difference in mean scores on the Rotterdam Symptom Checklist found
between these two groups with regard to physical problems (6.0 v. 10.5) suggests that this
study lacked sufficient power to detect meaningful differences.

Table 5. Analytic studies of physician-patient communication during discussion of the management plan

Summary
In the studies that examined discussion of the management plan, patient education was
found to influence both emotional and physiologic status, and physician education was found
to influence emotional status. All seven of the RCTs and six of the eight analytic studies
found significant correlations between communication interventions or variables and patient
health outcomes. The aspects of communication relevant to discussion of the management
plan that were found to significantly influence health outcomes are summarized in Table 6.

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Table 6. Elements of effective discussion of the management plan

Studies of other aspects of communication and patient health

outcome
The design and results of three RCTs and one analytic study of aspects of physician-patient
communication other than those relevant to history-taking and discussion of the management
plan are summarized in Table 7. The analytic study [36] found a nonsignificant association
between diabetic patients' recall of specific items of information given by the physician and
diabetes control.

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Table 7. Studies of physician-patient communication other than during history-taking and discussion of management plan

In one RCT [37] the physician randomly varied his approach to symptomatic patients for
whom no definite diagnosis could be made: half of the patients were provided with a
conventional, firm diagnostic label and a medication, whereas the other half were told that
there was no evidence of disease and that no treatment was required. No significant
difference in patient outcome was found between these two approaches.

In a second RCT [38] symptomatic patients with no definite diagnosis were randomly
assigned to receive either a directive or a sharing style of communication. In the former, the
physician made definitive statements about diagnosis, treatment, prognosis and follow-up. In
the latter, the physician asked the patient's opinion about the problem, diagnosis, treatment,
prognosis and follow-up. No significant differences were found between the two groups in
their perception of outcome.

In a third, similar, RCT [39] symptomatic patients had either a "positive" consultation with
the physician, in which they were given a firm diagnosis and a confident statement that they
would be better in a few days, or a "negative" consultation, in which the physician said "I
cannot be certain what is the matter with you" and either gave no treatment or said that it was
not certain that the treatment provided would have any effect. Of the patients who received
positive consultations, 64% felt significantly healthier after 2 weeks; of those who received
negative consultations, 39% felt better after that time.

No clear indication of recommended communication styles emerged from these four

studies.

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DISCUSSION
Patient health outcomes can be improved with good physician-patient communication. The
studies reviewed here suggest that effective communication exerts a positive influence not
only on the emotional health of the patient but also on symptom resolution, functional and
physiologic status and pain control. When taking a history, physicians should ask a wide
range of questions, not only about the physical aspects of the patient's problem, but also
about his or her feelings and concerns, understanding of the problem, expectations of therapy
and perceptions of how the problem affects function. Patients need to feel that they are active
participants in care and that their problem has been discussed fully. Patients should share in
decision making when a plan for management is formulated. They should be encouraged to
ask questions and given clear verbal information supplemented, when possible, by emotional
support and written information packages. Agreement between patient and physician about
the nature of the problem and the course of action appears to bode well for a successful
outcome.

The findings of this review may be subject to publication bias. An attempt to overcome
this was made by the inclusion of unpublished papers presented at meetings or referred to in
annotated bibliographies. None the less, studies that obtained negative results may have been
more likely than those that obtained positive results to escape the wide net of the search.

The dimensions of communication that the studies found to be effective have also been
described by clinicians and educators as valuable components of communication. Pendleton
and associates [17] and Levenstein and collaborators [40] focused on the need for the physician
to attend to the whole of the patient's problems and to take his or her expectations, feelings
and ideas into account. Weston, Brown and I [41] have described this as exploring the disease
and the "illness experience" during history-taking.

Riccardi and Kurtz [42] emphasized especially the importance of giving clear information
during discussion of the management plan. Brown, Weston and I [43] called this component
of the physician-patient interview "finding common ground," a phrase that suggests that
agreement between patient and physician is the preferred endpoint; this contrasts with the use
of the term "negotiation," with its confrontational overtones, to describe this segment of a
consultation.

The striking similarities between the body of research reviewed in this paper and
conceptual writings should encourage the medical profession to move toward a common
understanding of excellent communication -- one that can provide the basis for further
education and research.

Sharing power
What are the implications of the understanding of effective communication suggested
here? According to some authors, [44,45] improvement in communication requires a shift in
the balance of power between physician and patient. Some of the studies reviewed here dealt
explicitly with the issue of power and control. In one, [33] the fact that a woman was able to
choose the kind of breast surgery to have was not found to be related to emotional health
outcomes. In another, [34] going to a surgeon who permitted (but did not force) the choice
was found to be related to positive outcomes. I would suggest, therefore, that it was not
simply the decision-making power of the patient that was effective but, rather, the provision
of a caring, respectful and empowering context in which a woman was enabled to make an
important decision with both support and comfort. As well, agreement between physician and
patient was found to be a key variable that influenced outcomes [9,35]. In my view, such
agreement implies that decision making was a shared, egalitarian process. These four studies

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taken together debunk the myth that the only alternative to the physician's total control of
power in the therapeutic relationship is his or her total abdication of power. They indicate
that patients do not benefit from the physician's abdication of power but, rather, from
engagement in a process that leads to an agreed management plan.

EDUCATION
Curriculum development in the area of communication at all levels of medical education is
warranted on the basis of the study findings reviewed here. It is certainly justifiable to
identify physician-patient communication as a "central clinical function." [1]

Patient education with regard to communication has been shown to be highly effective and
deserves much more concerted attention in clinical settings. The provision of information
packages and of waiting-room training sessions are two strategies that were proven to be
successful in the studies reviewed.

FUTURE RESEARCH
Future research is recommended along three lines. First, initiatives in the domain of both
medical and patient education are needed and will require rigorous evaluation. Effectiveness
studies with regard to acceptability of the programs, behavioural change of physicians and
patients, and patient outcomes are warranted.

Second, cohort studies are still needed to assess the association of communication
measures not yet studied, such as the Davis Observation Code [46] and the Patient-Centred
Measure, [47] with patient outcomes. This review has indicated the importance of controlling
for baseline health and other potential confounding variables in research of this kind.

Third, because communication is an interactive process, qualitative studies would be

particularly helpful. Shared decision making leading to agreement between patient and
physician is one example of an interactive process that requires full description of the kind
that is possible only in qualitative research approaches.

The collaboration of the Canadian Library of Family Medicine in conducting the literature
searches is gratefully acknowledged.

Dr. Stewart is a member of a research team supported by the Health Systems Linked
Research Unit Program, Ontario Ministry of Health. The conclusions in this paper are those
of the author, and no endorsement by the ministry is intended or inferred.

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